sidhu p. gangadharan, md chief, division of thoracic surgery and interventional pulmonology beth...
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SIDHU P. GANGADHARAN, MDChief, Division of Thoracic Surgery and Interventional
Pulmonology
BETH ISRAEL DEACONESS MEDICAL CENTERBOSTON, MA
WHO SHOULD BE RESPONSIBLE FOR THE INITIAL
DIAGNOSIS AND STAGING OF LUNG CANCER?
NON-SURGEONS
SIDHU P. GANGADHARAN, MDChief, Division of Thoracic Surgery and Interventional
Pulmonology
BETH ISRAEL DEACONESS MEDICAL CENTERBOSTON, MA
WHO SHOULD BE RESPONSIBLE FOR THE INITIAL
DIAGNOSIS AND STAGING OF LUNG CANCER?
NON-SURGEONS
NOT ONLY
Outline of arguments
• Expertise
• Finances
Venn diagrams
Venn diagrams
Harvard graduates
US Presidents
Venn diagrams
Plays that score
touchdowns on second and goal
from the 2 yard line
Safe plays
Run plays
Wilson to Lockette,
INT by Butler
Venn diagrams
Surgeons Only Include Non-surgeons
Interventional pulmonology
RadiologyGeneral
practioner
GI
Moving beyond wars of turf
• Control of work-up
• Control of treatmentIssues of expertise
Specter of cardiac
angiography• Ownership argument
• Slippery slope
argument
• Technique argument
Control of work-up
Multidisciplinary cancer care
Ownership of the lung
cancer patient
Bjegovich-Weidman M. J Oncol Pract. 2010 Nov;6(6):e27-30.
Should surgeons do
brain biopsies?
Diagnosis of advanced
cancer
Jemal A. CA Cancer J Clin 2010;60:277-300.
Performance profile of
biopsy• Low yield FNA
Early stage lesions
Shimizu K. Lung Cancer 2006;51:173–179.
Performance profile of
biopsy
Early stage lesions
Shimizu K. Lung Cancer 2006;51:173–179.
Hammer/nail does not apply
• Ownership is linked to
treatment, not work-up
• Many patients present
with advanced disease
not requiring
interventional work-up
• Many patients with early
stage only managed by
surgeon
• Multidisciplinary team
approach logical
Ownership
Will surgical treatment
decline?
• Staging and diagnosis
already encompasses
multiple non-surgical areas
• Clear line between work-up
and treatment
• Adapt with technology (vascular
vs. cardiac)
• Rules of engagement are
crucial• Radiation oncology• Endobronchial therapy
• Not unique to AMC
Slippery slope
considerations
Who does it better?
• Learning curve
Technique
Hu Y. J Thorac Cardiovasc Surg 2013;146:1387-92
Stather M. Respirology (2015) 20, 333–339
Who does it better?
• Limited numbers in
general practice
• BIDMC
• 400 EBUS FY2014
• 75% lung cancer
staging/dx
Technique
Hu Y. J Thorac Cardiovasc Surg 2013;146:1387-92
Stather M. Respirology (2015) 20, 333–339
Is the pie big enough to
share?• Impact on individual
P/L
• Impact on
institutional bottom
line
Issues of finances
EBUS contributes to medical center
bottom line
• $24,742/NP EBUS referral
• $19,174 technical fee/NP EBUS
Downstream revenue
Pastis N. CHEST 2012;141(2):506-512
EBUS contributes to medical center
bottom line
• Technical fee per EBUS much
lower
• High volume tertiary care
setting results may not be
transferable
• Assumption about EBUS
driving NP volume
Weakness of argument
Thoracic surgery contributes to
hospital bottom line
Contribution
margin/wRVU
Resnick A. Ann Surg 2005;242: 530–539
Thoracic surgery contributes to
hospital bottom line
Margin higher without
diagnostic/staging
procedures
• BIDMC contribution
margin TS >IP
• wRVU/case 4-5x more
McKenna R. Ann Thorac Surg 2007;84:1663-1668
Summary
• Intake and treatment
determines ownership
• Responsibility is not exclusive
• Many diagnostic/staging
procedures logically done by non-
surgeons
• Many patients undergo
diagnostic/staging at the time up
upfront resection
• Fear of loss of treatment
authority mitigated by
multidisciplinary care
• Increased surgeon profitability
with higher proportion of
procedures that non-surgeons
cannot do
Why non-surgeons
should have
responsibility for
diagnosis and staging
